Club Injury / Accident Report Form

Injury/Incident Report

Gymnastics NSW
Office Use Only - Report File Number
Name of person completing form*

First NameLast Name
Email of Person completing Form*
example@example.com
Severity of injury *
If incident is major reportable:

1. Contact Integrity at GNSW - integrity@gymnsw.org.au

2. Report incident to Safe Work NSW - 13 10 50
Role of person completing form*
e.g. club owner, club administrator, physio, coach, event manager
Location of injury/incident *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date when injury/incident occurred*

DayMonthYear
Date
Hour MinutesAM/PM Option
Location of gym where injury occurred:*
Area in the gym, eg..: trampoline, floor, bars etc..
Date when symptoms of injury/incident evident *

DayMonthYear
Date
Hour MinutesAM/PM Option
Personal Details of Injured Person
Name of Injured Person*

First NameLast Name
Gymsport injured person was primarily involved with at time of injury:*
Date of Birth*

DayMonthYear
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Post Code
Injured person*

AthleteCoachOther
Gender*

MaleFemaleNon-binaryOther
Accident Details
Supervising coach at the time of the injury *

First NameLast Name
Signature of supervising coach *

Clear
First Aid Provided by*

First NameLast Name
Signature of person providing First Aid*

Clear
Did the accident occur during*

TrainingCompetitionWarm-upOther
Nature of the injury

NewAggravatedRecurring
Has an ambulance been recommended by First-Aid provider?*

YesNoN/A
Initial treatment provided:*

No treatment requiredCPRCrutchesDressingMassageRICERSling/SplintStrappingStretchingOther
Follow-up action required:*

NoneAmbulanceMedical Practitioner / PhysioHospitalOther
Symptoms of the injury*

BlistersBleedingBleeding noseBruising / contusionBurnCardiac problemChokingConcussion / head injuryCrampCutDislocationElectrical shockGraze / abrasionInflammationInsect bite / stingLoss of consciousnessPoisoningRespiratory problemSpinal injurySprainStrainSuspected bone fracture / breakOpen wound/laceration cutOveruse injuryOther
Full description of injuries:*
Detail body parts) injured:*
What activity lead to the injury?*

Collision with fixed objectCollision / contact with another personFall from heightFall / stumble at same levelOverbalanceOverstretchSlip/TripRunning/Run upJumpingTwist/TurnLandingOther
If other, detail the activity *
Describe in FULL DETAIL what occurred:*
Use full names of any persons involved and age of any child/young person. Include any extra detail regarding how the injury occurred.
Any additional information on follow-up treatment required*
Details provided to injured person; e.g. referred to see personal physiotherapist
Subsequent treatment (if known):*
Signature of person completing form*

Clear
Date*

DayMonthYear
Date
Name of Supervisor / Manager*

First NameLast Name
Signature of Supervisor / Manager*

Clear
Date*

DayMonthYear
Date
Name of Parent / Guardian*

First NameLast Name
When was parent/guardian notified*
Phone Number of Parent / Guardian *
Please enter a valid phone number.
Email of Parent / Guardian*
example@example.com; A copy of this form will be sent to the email provided
Supervising Coach*

First NameLast Name
Statement by Supervising Coach *
Describe what happened. Use the full name of all people involved.
Supervising Coach Signature*

Clear
Witness statements completed:*

YesNoN/A
Additional notes:*
Attach any other relevant documents and/or photos:

Cancelof
Video Upload

Cancelof
Additional Email Address
List any additional email addresses the form is to be sent to here
Should be Empty:

Injury/Incident Report

Personal Details of Injured Person

Accident Details